November 16, 2017
7 PM CT/8 PM ET/5 PM PT

Topic: Physical Therapy in Women's Health
Speaker: Carol Figuers, MS, PT, EdD, Professor, Doctor of Physical Therapy Division, Duke University School of Medicine

In Seattle, an increasing number of gonorrhea infections in men who have sex with men have demonstrated reduced susceptibility to azithromycin - one of two drugs recommended to treat the increasingly drug-resistant STD.  

California Governor Jerry Brown has signed first-of-its kind legislation that enables residents of the state to choose a third, non-binary gender category on California state-issued IDs, birth certificates and driver's licenses.

One common cause of false positives are so-called "high-risk" lesions that appear suspicious on mammograms and have abnormal cells when tested by needle biopsy. In this case, the patient typically undergoes surgery to have the lesion removed; however, the lesions turn out to be benign at surgery 90 percent of the time. This means that every year thousands of women go through painful, expensive, scar-inducing surgeries that weren't even necessary.

How, then, can unnecessary surgeries be eliminated while still maintaining the important role of mammography in cancer detection? Researchers at MIT's Computer Science and Artificial Intelligence Laboratory (CSAIL), Massachusetts General Hospital, and Harvard Medical School believe that the answer is to turn to artificial intelligence (AI).

As a first project to apply AI to improving detection and diagnosis, the teams collaborated to develop an AI system that uses machine learning to predict if a high-risk lesion identified on needle biopsy after a mammogram will upgrade to cancer at surgery.

When tested on 335 high-risk lesions, the model correctly diagnosed 97 percent of the breast cancers as malignant and reduced the number of benign surgeries by more than 30 percent compared to existing approaches.

"Because diagnostic tools are so inexact, there is an understandable tendency for doctors to over-screen for breast cancer," says Regina Barzilay, MIT's Delta Electronics Professor of Electrical Engineering and Computer Science and a breast cancer survivor herself. "When there's this much uncertainty in data, machine learning is exactly the tool that we need to improve detection and prevent over-treatment."

Trained on information about more than 600 existing high-risk lesions, the model looks for patterns among many different data elements that include demographics, family history, past biopsies, and pathology reports.

When a mammogram detects a suspicious lesion, a needle biopsy is performed to determine if it is cancer. Roughly 70 percent of the lesions are benign, 20 percent are malignant, and 10 percent are high-risk lesions.

Doctors manage high-risk lesions in different ways. Some do surgery in all cases, while others perform surgery only for lesions that have higher cancer rates, such as "atypical ductal hyperplasia" (ADH) or a "lobular carcinoma in situ" (LCIS).

The first approach requires that the patient undergo a painful, time-consuming, and expensive surgery that is usually unnecessary; the second approach is imprecise and could result in missing cancers in high-risk lesions other than ADH and LCIS.

"The vast majority of patients with high-risk lesions do not have cancer, and we're trying to find the few that do," says Bahl, a fellow doctor at MGH's Department of Radiology. "In a scenario like this there's always a risk that when you try to increase the number of cancers you can identify, you'll also increase the number of false positives you find."

Using a method known as a "random-forest classifier," the team's model resulted in fewer unnecessary surgeries compared to the strategy of always doing surgery, while also being able to diagnose more cancerous lesions than the strategy of only doing surgery on traditional "high-risk lesions." (Specifically, the new model diagnosed 97 percent of cancers compared to 79 percent.)

"This work highlights an example of using cutting-edge machine learning technology to avoid unnecessary surgery," says Marc Kohli, director of clinical informatics in the Department of Radiology and Biomedical Imaging at the University of California at San Francisco. "This is the first step toward the medical community embracing machine learning as a way to identify patterns and trends that are otherwise invisible to humans."

Lehman says that MGH radiologists will begin incorporating the model into their clinical practice over the next year.

"In the past we might have recommended that all high-risk lesions be surgically excised," Lehman says. "But now, if the model determines that the lesion has a very low chance of being cancerous in a specific patient, we can have a more informed discussion with our patient about her options. It may be reasonable for some patients to have their lesions followed with imaging rather than surgically excised."

The team says that they are still working to further hone the model.

"In future work we hope to incorporate the actual images from the mammograms and images of the pathology slides, as well as more extensive patient information from medical records," says Bahl.

Moving forward, the model could also easily be tweaked to be applied to other kinds of cancer and even other diseases entirely.

"A model like this will work anytime you have lots of different factors that correlate with a specific outcome," says Barzilay. "It hopefully will enable us to start to go beyond a one-size-fits-all approach to medical diagnosis."

Explore further: Machine learning identifies breast lesions likely to become cancer

Endocrine Today, October 2017

Many adolescents and young adults may believe that obesity-related diseases, such as heart disease, diabetes and osteoarthritis, are concerns of old age. But excess weight can have detrimental effects on fertility, a consequence younger adults may not recognize until they want to start a family.

Although age is the greatest predictor of fertility among women, obesity has a substantial effect on the likelihood of pregnancy. For example, the likelihood of pregnancy may be similar between a young woman with BMI greater than 30 kg/m2and a woman aged older than 35 years, according to Nanette Santoro, MD, the E. Stewart Taylor Endowed Chair in the department of obstetrics and gynecology and professor in the division of reproductive endocrinology at the University of Colorado Denver Anschutz Medical Campus

“So, if she were 25 years old, she would have the fertility of a woman approaching 40 years, in her ability to get pregnant per month,” Santoro told Endocrine Today.

Obesity has effects throughout the hypothalamic-pituitary-gonadal axis in both men and women, according to Rhoda H. Cobin, MD. Source: Jean Whiteside Photo; printed with permission.

Further, “there is a 3% drop in monthly fecundability for each BMI unit above 25 kg/m2. So, for a woman with a BMI of 35 kg/m2, she has a 30% drop in her fertility by this measure,” she said. “There is a ‘dose-response’ relationship — the greater the obesity, the more likely the infertility.”

Obesity affects not only fecundability — the probability of pregnancy in a given month — but it also is associated with increased risk for spontaneous abortion, congenital anomalies, gestational diabetes and preeclampsia, according to a 2015 American College of Obstetricians and Gynecologists (ACOG) Obesity in Pregnancy Practice Bulletin. Risk for stillbirth, although low, is increased by 30% for women with BMI 30 kg/m2 to 34.9 kg/m2 and almost doubles with BMI 40 kg/m2and higher, according to the bulletin.

Maternal obesity may also affect the long-term health of children, elevating their risks for metabolic syndrome and childhood obesity, according to ACOG. However, separating prenatal effects from influences after birth is difficult.

Obesity is not a concern only for women; men with obesity may also have decreased fertility.

“We tend to think of this as a women’s issue, but it actually takes two people to make a baby,” Rhoda H. Cobin, MD, clinical professor of medicine in the division of medicine, endocrinology and bone disease at the Icahn School of Medicine at Mount Sinai School, told Endocrine Today. “Obesity affects men’s fertility as well as women’s fertility, so when people talk about infertility, they’re really talking about a couple.”

PHILADELPHIA -- Menopause-related depression was mitigated with transdermal estradiol (E2) plus progesterone in a randomized trial reported here.

One year of treatment with 0.1 mg of E2 added to 200 mg micronized intramuscular progesterone significantly decreased incidence of clinically significant depressive symptoms compared to those assigned to placebo (17.3% versus 32.3%, P<0.05), according to Jennifer L. Gordon, PhD, of the University of Regina in Saskatchewan, Canada, and colleagues.

Women who were not on hormonal treatment were also more likely to report a score of 16 or greater on the CES-D scale at least once during treatment compared to women on estradiol treatment (OR 5.3, 95% CI 1.8-15.8, P<0.01), presented at the annual meeting of The North American Menopause Society.

A total of 172 perimenopausal or early postmenopausal women, who were medically healthy and without a diagnosis of major depressive disorders, bipolar, or any other psychotic disorder at time of enrollment, were randomized 1:1 to active treatment or placebo. All participants were community-dwelling women ages 45-60 and were not taking any medications to confound cardiovascular or endocrine profiles.

Transdermal estradiol was dosed at 0.025 mg for 2 weeks, then increased to 0.05 mg for 4 weeks, and then remained at 0.1 mg for the rest of the study. This was paired with micronized progesterone at 200 mg, which was administered for 12 days, every 2 to 3 months. The control group was provided placebo patches and pills.

Participants were evaluated seven times during the 12-month study. Depressive symptoms were defined at a rate score of 16 or higher on the Center for Epidemiologist Studies-Depression Scale, and bothersome level of vasomotor symptoms were measured according to the Greene Climacteric Scale.

Beneficial treatment effects of E2 and IMP therapy compared to placebo were seen among early perimenopausal women, but were not seen among postmenopausal women. The authors suggested that one possible underlying mechanism to explain this finding might be attributed to the stabilization of fluctuating estradiol levels.

A significant interaction between treatment and recent stressful life events on depressive symptoms reported by the CES-D scale was also noted. Among women who reported high amounts of stressful life events prior to study inception, CES-D score was significantly lower among the TE+IMP group compared to placebo.

Gordon's group also found that prior history of depression, physical or sexual abuse, and baseline vasomotor symptoms and E2 levels were not significant moderators of the treatment effects.

"If confirmed in future research, clinicians may consider using transdermal estradiol as a prophylactic treatment for depressive symptoms in the menopause transition," Gordon stated during an oral presentation of the findings.

During a Q&A following the presentation, a member of the audience inquired as to why the research group chose such a high dose of estradiol. Gordon replied that 0.1 mg has been found to decrease ovulation in the menopause transition and stabilize the hormonal environment compared to lower doses, and the group aimed to find if stabilization of the environment was tied to improved mood.

The research was supported by two NIH grants.

Gordon reported no conflicts of interest.

• Primary Source

  North American Menopause Society

  Source Reference: Gordon J, et al "Antidepressant effects of transdermal estradiol in the menopause transition are moderated by stressful life events" NAMS 2017; Abstract S-23.

FRIDAY, Oct. 6, 2017 (HealthDay News) -- In a move that could affect millions of American women, the Trump Administration is poised to roll back a federal mandate requiring that birth control be available as part of employer-based health plans.

Instead, new rules -- expected as early as Friday -- would give employers much wider leeway to declare themselves exempt from providing contraception due to moral or religious objections, The New York Times reported.

More than 55 million women currently have access to free birth control due to the contraceptive coverage mandate, according to data compiled under the Obama administration. The new rules would also affect hundreds of thousands of women who get free contraception under the Affordable Care Act.

The expected action from the White House fulfills a promise President Donald Trump made to voters during the 2016 election campaign.

According to the Times, wording in the new rules offers an exemption to any employer based on "moral convictions" or because it objects to covering birth control services "based on its sincerely held religious beliefs."

The Trump administration wording says that expanding exemptions was needed so that all religious objections to contraceptive coverage could be accommodated. "Application of the mandate to entities with sincerely held religious objections to it does not serve a compelling governmental interest," it says.

The birth control mandate was the focus of intense litigation during the Obama Administration, as companies, hospitals, charitable groups and other organizations with moral objections sought to distance themselves from providing birth control to female employees. In one such case, an order of nuns called the Little Sisters of the Poor said the mandate would make them "morally complicit in grave sin," the Times reported.

On the campaign trail, Trump told voters that he would "make absolutely certain religious orders like the Little Sisters of the Poor are not bullied by the federal government because of their religious beliefs."

But the new move is expected to prompt even more legal battles -- this time from groups advocating for women and public health.

In a statement, Dr. Anne Davis, consulting medical director for Physicians for Reproductive Health, said the rollback could send many American women "back to the days when patients couldn't afford the birth control that helps them live healthier lives."

"No matter where they work, women need and deserve birth control access," Davis said. "An employer's beliefs have no place in these private decisions, just as they would not in any other conversation about a patient's health care. It's a dangerous intrusion into a woman's privacy and her ability to get the care she needs."

Dana Singiser, Planned Parenthood's vice president of public policy and government affairs, agreed.

"Let's be clear: this rule has nothing to do with religion. Under the Affordable Care Act religious organizations already have an accommodation that still ensures their employees get coverage through other means," she said. "This rule is about taking away women's fundamental health care, plain and simple."

But the Trump administration said that in expanding exemptions, it is honoring objections to contraceptive coverage on moral as well as purely religious grounds.

"Congress has a consistent history of supporting conscience protections for moral convictions alongside protections for religious beliefs," the administration said.

Companies that now decide to opt out of contraceptive coverage are required to notify employees, the new rules state.

The new rules are to take effect immediately, the Trump administration said, because "it would be impracticable and contrary to the public interest to engage in full notice and comment rule-making." Public comments are being accepted, however.

More information

There's more on contraception at the American College of Obstetricians and Gynecologists.

SOURCES: The New York Times; Oct. 5, 2017, news releases, Planned Parenthood Federation of America, Physicians for Reproductive Health

-- E. J. Mundell

Last Updated: Oct 6, 2017

Copyright © 2017 HealthDay. All rights reserved.

by Michael Smith, North American Correspondent, MedPage

October 06, 2017

Action Points

SAN DIEGO -- A few extra glasses of water a day could cut the risk of urinary tract infections for women plagued with recurrent episodes, a researcher said here.

In a randomized trial, drinking about three extra pints of water a day cut the risk of uncomplicated acute cystitis (AUC) by about half, according to Thomas Hooton, MD, of the University of Miami School of Medicine.

The extra water was also associated with fewer courses of antibiotics during the year-long study, Hooton told reporters here at the annual IDWeek meeting, sponsored jointly by the Infectious Diseases Society of American (IDSA), the Pediatric Infectious Diseases Society (PIDS), the Society for Healthcare Epidemiology of America (SHEA), and the HIV Medicine Association (HIVMA).

The finding is not really a surprise, Hooton said -- doctors have long been telling women to drink more water to prevent or help treat recurring AUC.

The idea makes sense, he said, because the conventional wisdom has been that disease-causing bacteria make their way from the vagina up the urethra to the bladder. Frequent flushing with urine can prevent the bacteria from sticking to bladder cells, growing, and causing disease.

But while that's a good story, he said, there had been no real study of the issue. "You always want to have confirmatory data," Hooton said. "It helps to be able to say there's a well-done study that looked at this question very carefully and showed the risk was pretty dramatically reduced."

To obtain that data, he and colleagues enrolled 140 premenopausal women whose self-reported fluid intake was low -- less than 1.5 liters of total fluid a day -- and who had had at least three episodes of AUC in the previous year.

They were randomly assigned 1:1 to increase their water intake by 1.5 L a day or to make no change in their habits.

The investigators had monthly telephone calls with all participants as well as regular clinic visits in which such things as urine volume and osmolality -- a measure of the concentration of the fluid -- were tested.

Women in the intervention group were given 500 mL bottles of water and urged to begin drinking one at the start of each meal and to finish it before the next meal, Hooton said.

Over the study period, the 70 women in the intervention group:

• Increased their water intake significantly compared with the control group -- an increase of 1.15 L on average versus an average drop of 0.01 L
• Raised their average total fluid intake by 1.65 L versus 0.03 L among the control group
• Upped average urine volume and number of urine voids -- 1.40 L versus 0.04 L and 2.2 a day versus a decrease of 0.2, respectively
• Saw a decrease in urine osmolality of 408 mOsm/kg versus 35 in controls

But the key finding, Hooton said, was that the average number of recurrent AUC episodes in the water group over the year was 1.6, compared with 3.1 among the control women. Those number yielded an odds ratio for AUC of 0.52, which was highly significant, he said.

As might be expected, the average number of antimicrobial regimens used to treat AUC was 1.8 in the water group and 3.5 in the control group, which was again significant. As well, he noted, the average number of days to first AUC after the start of the study and the mean number of days between episodes was longer for those in the water group.

The findings are important because many women suffer recurrent AUC and most are treated with antibiotics, commented Susan Bleasdale, MD, of the University of Illinois at Chicago, who moderated a media briefing on the trial.

The study, she told reporters, "may be a game-changer" in the way antibiotics are used.

The usual advice doctors give women to keep hydrated often comes when they are already in the throes of an infection -- advice often given along with a prescription for antibiotics. The point of the study, she said, is that increased water intake appears to prevent the infections in the first place -- and therefore the need for scripts.

While the study took place among premenopausal women at risk for recurrent AUC, Hooton said he sees no reason it would not apply to those past the menopause, as well as to women of all ages who suffer less frequent attacks. But he added that hasn't yet been demonstrated.

Hooton said he had no disclosures to make.

The study had support from Danone Research.

Bleasdale made no disclosures.

• Reviewed by Henry A. Solomon, MD, FACP, FACCClinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  IDWeek 2017

  Source Reference: Hooton T, et al "Prevention of recurrent acute uncomplicated cystitis by increasing daily water in premenopausal women : A prospective randomized controlled study" IDWeek 2017; abstract LB-7.

Julia Haskins

Exposure to extreme heat may lead to problems with pregnancy and birth outcomes, a recent study finds.

According to the study, published in July in the International Journal of Environmental Research and Public Health, exposing pregnant women to extreme temperatures can lead to problems related to length of gestation and birthweight, neonatal stress and stillbirth.

Study researchers conducted a literature review of the effect on climate change on maternal, fetal and neonatal health. They found evidence of adverse outcomes across studies, with preterm birth being the most common.

Exceeding a heat threshold was found to be a bigger driver of adverse outcomes than duration of heat exposure. According to the study, “data show that surpassing historical temperature percentiles in each city resulted in an adverse birth outcome of some kind across all studies.”

Pregnant women need to be concerned about heat exposure, said study author Sabrina McCormick, PhD, associate professor of environmental and occupational health at the Milken Institute School of Public Health at the George Washington University.

“We often normalize the heat...but when it comes to pregnant women, it may be that we need to be more cautious than we have to date,” McCormick told The Nation’s Health. “(We need) to reconceptualize heat as another risk that pregnant women have to consider as they go about their day-to-day activities.”

Climate change has been linked to increasing temperatures around the globe, and 2016 was the warmest year ever recorded.

McCormick said she would like to see health care providers become more educated about extreme heat linked to climate change and communicate the dangers of extreme heat exposure with pregnant patients in regular conversations.

Environmental policy also has the potential to influence the health outcomes of pregnant women, particularly in terms of reducing the urban heat island effect, McCormick said. The urban heat island effect refers to metropolitan areas that are much warmer than surrounding rural areas due to human activity and the absence of green spaces.

“It’s extremely important that both policymakers and individual cities...attempt to reduce the urban heat island effect through increasing access to green space and green coverage in general,” she said.

Public health has an equally important role in communicating the importance of staying cool in high temperatures. McCormick noted that while heat advisories are often geared toward at-risk groups such as children and elderly people, pregnant women are rarely included in such messaging. She said she would like to see public health warnings about extreme heat specifically target pregnant women, who are also at high risk for heat-related illness.

In addition, because pregnancy is often a time for women to reconsider their health behaviors, being more environmentally conscious can also be part of making good prenatal health decisions, according to McCormick.

“When we think about the transgenerational effects of climate change — which there are and there will be more of — this kind of research shows how (what) we’re doing today will affect our children (and) our children’s children,” she said. “It’s an important reflection on why we need to be taking action.”

For more information, visit http://www.mdpi.com/1660-4601/14/8/853/htm.

• Copyright The Nation’s Health, American Public Health Association

Women: Take five! Or less! Learn about five things you can do that can go a long way to improve or maintain good health.

In Five Minutes or Less, You Can:

1. Learn about the number one killer of women.
   Heart disease is the leading cause of death for women in the United States. Learn the symptoms of a heart attack and stroke. You can save a life by knowing the signs and symptoms!
2. Schedule a check-up. 
   Regular check-ups are important. Schedule an appointment with your health care provider to discuss what screenings and exams you need and when you need them.
3. Protect your skin from the sun. 
   Skin cancer is one of the most common cancers among women in the United States. In just minutes you can protect your skin and put on broad spectrum sunscreen with at least SPF 15 before you go outside, even on slightly cloudy or cool days.
4. Find an HIV, STD, and Hepatitis testing site near you. 
   Untreated sexually transmitted diseases (STDs) can have long-term consequences [221 KB] for women, such as infertility. Find testing near you to know your status.
5. Take folic acid before and during pregnancy.
   The B vitamin folic acid can help prevent certain birth defects. If a woman has enough folic acid in her body before and during pregnancy, her baby may be less likely to be born with certain birth defects of the brain or spine. All women who could possibly get pregnant should take 400 micrograms of folic acid every day in a vitamin or in foods that have been enriched with it.

These tips are just a few of the many things you can do in five minutes or less. Learn more small steps you can take to improve your health.